Other Relevant Forms

<– Back to Resources Page

Utilization Review Complaint Forms
Utilization Review Forms – DWC UR Form 1

Pre-designation of Personal Physician / Change of Physician Forms
Notice of Pre-designation of Personal Physician Form – DWC Form 9783

Notice of Personal Chiropractor or Acupuncturist – DWC Form 9783.1

Primary Treating Physician Forms
Primary Treating Physician Permanent and Stationary Report (2005 rating schedule) – DWC Form PR-4

Primary Treating Physician Permanent and Stationary Report (1997 rating schedule) – DWC Form PR-3

Primary Treating Physician’s Progress Report – DWC Form PR-2

Application for Independent Medical Review (for employee)

Utilization Review Complaint Form (for provider)

Predesignation of Personal Physician Form – DWC Form 9783

Request for Independent Bill Review

Providers Request for Second Bill Review

Official Medical Fee Schedule Order Form

Doctor’s First Report of Injury

Request for Authorization for Medical Treatment

Physician’s Return to Work and Voucher Form

Medical Provider Network (MPN) Forms
Cover page for medical provider network application – DWC form 9767.4

Independent medical review application (for injured workers who need to get an independent medical review) – DWC form 9768.10

Notice of medical provider network plan modification Labor Code 9767.8 – DWC form 9767.8

Physician contract application (for doctors who want to become independent medical reviewers) – DWC form 9768.5

Sample initial written employee notification re: Medical provider network